38A-003 (2) 18 BURTS PIT RD BP-2020-0862
GIS#: COMMONWEALTH OF MASSACHUSETTS
Map:Block: 38A-003 ! CITY OF NORTHAMPTON
Lot: -001 PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
Permit: Building DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL 042A)
Categorv: INSULATION BUILDING PERMIT
Permit# BP-2020-0862
Project# JS-2020-001475
Est.Cost: $5282.00
Fee: $65.00 PERMISSION IS HEREBY GRANTED TO:
Const.Class: Contractor. License:
Use Group: GREEN COLLAR LLC 108817
Lot Size(sa.ft.): 17119.08 Owner. VATRENKO KONSTANTIN
Zoning, URB(100)/ Applicant. GREEN COLLAR LLC
AT. 18 BURTS PIT RD
Applicant Address: Phone: Insurance:
390 NEWTON ST (413) 532-1817 WC
SOUTH HADLEYMA01075 ISSUED ON.1/29/2020 0:00:00
TO PERFORM THE FOLLOWING WORK.-INSULATE ATTIC FLOOR
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector of Wiring D.P.W. Building Inspector
Underground: Service: Meter:
Footings:
Rough: Rotiah: House# Foundation:
Driveway Final:
Final: Final:
Rough Frame:
Gas: Fire Department Fireplace/Chimney:
Rough: Oil: Insulation:
Final: Smoke: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
Certificate of Occupancy Signature:
FeeTyne: Date Paid: Amount:
Building 1/29/,2020 0:00:00 $65.00
212 Main Street, Phone(413)587-1240,Fax: (413)587-1272
Louis Hasbrouck—Building Commissioner
Dep
OR
City of Northampt4
�... \
Building Department
212 Main Street ✓ SULATION
Room 100 /' QN �9
Northampton, MA 01:0.-
� phone 413-587-1240 Fax 413-58
ONLY
�,_
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY L�1fAG O LY
SECTION 1 -SITE INFORMATION INS ULA TION PERMIT
1.1 Property Address: ` p _A This section to be compl by office
1�( tu(-'�' ?'T ILO Q d Map Lot Unit
Nor4h affV0 U� 1'1. ,nIT O O � 0 Zone _Overlay District_
Iv VElm St.District CB District
SECTION 2-PROPERTY OWNERSHIP/AUTHORIZED AGENT
2.1 Owner of Record:
V . N6, en-Lb I &J(+S Pry 9-0� Nor
Name(Print) Current Mailing Addres
1- 6 - gLgD -
Telephone
Signature
2.2 Authorized Agent:
QI w, 3SI
Name(Print) Current Mailing Address:
4►3- "b2-- 181 r)
Signature Telephone
SECTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
com feted by permit applicant
1. Building (a)Building Permit Fee
sl2g� .
2. Electrical (b)Estimated Total Cost of
Construction from 6
3. Plumbing Building Permit Fee
4. Mechanical (HVAC)
5. Fire Protection
6. Total=(1 +2+ 3+4+5) S 16 2 Check Number44 oZ
This Section For Official Use Only
LII > , Date
Building Permit Number: �l�' UU/� Issued:
Signature:
Building Commissioner/Inspector of Buildings Date
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor: Not Applicable ❑
Name of License Holder: (
��J[ .V V S— `ola I r7
License Number
��a() N -ri�,� �Lc�alLe-+� M �) . 23 . 2 0
Address Expiration Date
Sig ture Telephone
9 Reaistered Home Imcrovement Contractor: Not Applicable ❑
PutM C n II u/- LLC, I $ I Ll I
Company Name Registration Number
Address Expiration Date
Telephone2 - 1�
SECTION 5-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152,§25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... ❑
Brief Description of Proposed Work [NOTE: INSULATION ONLY
C-1 VZ/
I, 2 C) ')1i l w1a^ (Pl as Owner/Authorized
Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
(`C � tr"u VIA
Print Name
t
Signature er/ gent Date
, as Owner of the subject
property
hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Signature of Owner Date
City of Northampton
-- .., s
y Massachusetts
�r DEPARTMENT OF BUILDING INSPECTIONS "
212 Main Street • Municipal Building
Northampton, MA 01060 tiJ��S� \1dCa`
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor must be registered as a Home Improvement Contractor("HIC").
M.G.L. Chapter 142A requires that the"reconstruction,alteration, renovation,repair, modernization, conversion,
improvement removal, demolition, or construction of an addition to any pre-existing owner-occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If the homeowner has`contracted with a corporation or LLC,that entity must be registered
Type of Work: (J a-+ c _ Est. Cost: _13 , a �S_a _
Address of Work: Yy r $ p + 0.d carte 0-M O Q--C)
Date of Permit Application: _
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
_Job under$1,000.00
_Owner obtaining own permit(explain):
Building not owner-occupied
Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBILITES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the
ne agent of the owner:
ntfbt
Date Contractor Name HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
.� " Massachusetts
DEPARTMENT OF BUILDING INSPECTIONS y
212 Main Street •Municipal Building
Northampton, MA 01060 J°ssp .. `�0ca
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility, as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
I S rxjr+ S Pt f p_C Ncy* a/r\ 't0 M O V O�-a 0
(Please print house number and street name)
Is to be disposed of at:
4Qlbl C J i c:PA
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and A(Ydress) KA r' 0 l
Signatu Permit Applicant or Owner Date
If, for any reason, the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
i
AftPermit Authorization
rmss saw Form
SWOWWW"AWWWOWAdwity
Site ID: 3952042 Customer. KONSTANTIN VATRENKO
I, �,OQ �'/► A' n U4�^� ,owner of the property located at:
(owners Name,pdnted)
18 Burts Pit Rd Northampton, MA 01060 _
(Property street Address) (cM)
hereby authorize the Mass Save Home Energy Services Program assigned Participating Contractor listed
below to act on my behalf and obtt a building permit to perform Insulation and/or weatherization
work on my property.
Owner's Signature:
Date: , Z4 I S
.....................................................................
FOR OFFICE USE ONLY
We have assigned the following Mass Save Home Energy Services Participating Contractor to the
above referenced project:
L L C
Participating Contractor Date
Name: CLEAResult
Phone: 800-480-7472
Email:
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I RG VV//{/ILV/{ryGLLLL/! UJ [Il ILJJILL/f L{JGLLJ
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/E1 Please Print Le bl
Applicant Information
Name(Business/organizaiion/Individual): Green Collar LLC
Address: 351-Newton St. Unit B
City/State/Zip: South Hadley,
MA 01075 Phone #: 413 532 1817
Are you an employer? Check the appropriate box: Type of project(required):
L® I am a employer with_ a� 4. ❑ I am a general contractor and I 6 E]New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet.
7. Remodeling
2.❑ I am a sole proprietor or partner- These sub-contractors have 8. ❑ Demolition
ship and have no employees
working for me in any capacity.
employees and have workers' 9 [:] Building addition
comp. insurance.$
[No workers' comp.insurance 10.0 Electrical repairs or additions
required.] 5. ❑ We are a corporation and its
3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs
c. 152,§1(4),and we have no
insurance required.]t 13.® Otherinsulation/Weatherization
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
AmGUARD Insurance Company - A Stock Co.
Insurance Company Name:_
Policy#or Self-ins.Lic.#:
R2WC053509 Expiration Date: 9/23/2020
Job Site Address: / E� )SII(Is ?t h U 0- City/State/Zip: �J(/r cu�`�' M• M
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
C31o1Q0
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perjury that the information provided above is true and correct.
Si natured '.� Date:
( _ (0 2 0
Phone#: 413 532 1817
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
Issuing
Contact Person: Phone#:
hire Hathaway Insurance* ,i
GUARDCm -poling � Cl ma[_m
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Tom LLC
ORM COLLAR LLC, R gl -radrwc 181415
w 351 NEWTON 8T UWr 8 03/3112021
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